Racial and ethnic disparities in the medical treatment of elderly ambulatory, hospitalized and long term care patients have been frequently documented. In addition, both access to nursing homes and the quality of care received by elderly patients in nursing homes, can be described as "separate" (nursing homes tend to be either well financed and located in resource-rich areas, or poorly equipped and located in poor communities) and "unequal" (poorer homes tend to have lower quality care processes and outcomes). Many factors are thought to contribute to this sorry picture, including patterns of residential segregation, local long term care (LTC) market structure, state level reimbursement policies, nursing home (NH)-level strategic decisions, and patient level characteristics which can influence the sorting of individuals into particular types of nursing homes, depending upon their location in different neighborhoods. This study will pursue five specific aims to untangle the effects of these various factors on NH access and quality of care differences. We will: 1) construct alternative measures of residential segregation based on patient residence (prior to nursing home entry); 2) examine patterns of segregation within local markets in access to nursing home care; 3) explore differences in NH-level quality of care within and between different segregation contexts; 4)develop and test two multi-level models to explain variation in quality of care levels across NHs, and differences in quality of care experienced by different racial/ethnic groups within NHs; and 5) explore two additional hypotheses concerning the implications of NH responses for disparities in care and segregated care settings. Lay Summary: Persons who are poor and minority are more likely to receive care in poorer quality nursing homes. This study seeks to identify possible solutions to the problem of differential access to nursing homes of vastly different quality, and to better position the LTC system to provide equal and appropriate care to an elderly population that will be increasingly nonwhite, female, in poor health, and with limited family assistance.